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House of Prayer/Canal Lake Bible Camp: 2009 Medical Release and Liability Waver

This document is a medical release and liability waiver form for House of Prayer/Canal Lake Bible Camp. It requests emergency contact and medical information for children attending events, including names, addresses, phone numbers, doctor and insurance details. The parent or guardian signs to authorize all necessary medical treatment and to waive their right to informed consent in emergencies when they cannot be reached. They also release the camp and individuals from liability for any accidents during camp activities.

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112 views1 page

House of Prayer/Canal Lake Bible Camp: 2009 Medical Release and Liability Waver

This document is a medical release and liability waiver form for House of Prayer/Canal Lake Bible Camp. It requests emergency contact and medical information for children attending events, including names, addresses, phone numbers, doctor and insurance details. The parent or guardian signs to authorize all necessary medical treatment and to waive their right to informed consent in emergencies when they cannot be reached. They also release the camp and individuals from liability for any accidents during camp activities.

Uploaded by

api-16288299
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

House of Prayer/Canal Lake Bible Camp

2009 Medical Release and Liability Waver

Emergency Contact and Medical Information

Child’s Name ________________________ Date of Birth ____________________ Sex M F

Parent’s/Guardian’s Name ______________________________________ Parent’s/Guardian’s Name _______________________________________

Home Phone ___________________ Work Phone_________________ Home Phone____________________ Work Phone ___________________

Address_____________________________________________________ Address _____________________________________________________

City, ST ZIP Code ____________________________________________ City, ST ZIP Code _____________________________________________

Alternative Emergency Contacts

Primary Emergency Contact ____________________________________ Secondary Emergency Contact ____________________________________

Home Phone ___________________ Work Phone_________________ Home Phone____________________ Work Phone ___________________

Address_____________________________________________________ Address _____________________________________________________

City, ST ZIP Code ____________________________________________ City, ST ZIP Code _____________________________________________

Medical Information

Hospital/Clinic Preference___________________________________________________________________________________________________

Physician’s Name _____________________________________________ Phone Number ______________________________________________

Insurance Company ___________________________________________ Policy Number ______________________________________________

Allergies/Special Health Considerations _______________________________________________________________________________________

I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or pre-
scribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the
event that neither parent/guardian can be reached in the case of an emergency.

Parent’s/Guardian’s Signature _____________________________________________________ Date ____________________________________

I give permission for my child to attend events, both on the campus and away. I release House of Prayer/Canal Lake Bible Camp, and all individuals
from liability in case of accident during activities related to House of Prayer/Canal Lake Bible Camp.

Parent’s/Guardian’s Signature _____________________________________________________ Date ____________________________________

Witness Signature _______________________________________________________________ Date ____________________________________

House of Prayer Interdenominational Church


Canal Lake Bible Camp
2925 Pat Colwell Rd. • P.O. Box 1475 • Blairsville, GA 30514 • 706-745-5925
www.houseofprayerblairsville.com

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